Fld Name /
|
Instruction |
(a) Name of Provider |
Enter the complete name of the Provider. |
(b) Name of Provider |
Enter the complete name of the Provider. |
(c) Signature of Provider |
Enter the signature of the Provider’s authorized representative. |
(d) Title of Provider |
Enter the title of the Provider’s authorized representative. |
(e) Date |
Enter the date of the signature of the Provider’s authorized representative. |
Page
| File Type | application/msword |
| File Title | Instructions for CCC-576 |
| Author | Preferred Customer |
| Last Modified By | Judy.Fry |
| File Modified | 2008-04-30 |
| File Created | 2008-04-30 |